眶周分块截骨术在眶颧部骨折导致的眼球错位病例中的运用

目的探讨运用眶周分块截骨术治疗因眶颧部骨折所致眼球错位的可行性及效果。方法 26例单侧非爆裂性颧骨骨折患者的眶颧部移位骨块被截成两部分,将参与构成眼眶外下部的骨块向内上移位、固定以重建眼眶,对于不影响眼眶重建的移位骨块不作截骨复位。结果术后眼眶容积及眼球凸度得到有效改善,23例眼球位置显著改善,3例眼球凹陷症状部分纠正。术后随访1年,眼球位置及眼眶形态满意。结论眶周分块截骨术较传统的截骨术式操作简单,术中剥离范围小,可以恢复眼眶的生理解剖结构,并可有效矫正因眶颧部骨折所致的眼球错位。     

外伤性眶颧部骨折治疗50例临床分析

目的探讨根据不同的损伤类型及程度，选择性运用眶周截骨术及眶内充填术，对50例眶颧部骨折患者的整复治疗效果。方法根据眶颧部骨折的不同损伤程度，采用眶壁眶缘截骨术，恢复眼眶的解剖结构，并根据骨块复位程度．选用自体或医用材料进行眶周和眶内骨膜下充填，修复眼眶。结果50例患者术后双侧眼球突出度、面中部对称性，宽度等均较手术前有明显改善。本组有2例长期复视，5例术后有轻度眼球凹陷。结论眶周截骨复位术，辅助选用眶内材料充填可以有效矫正陈旧性眶颧部骨折畸形。     

获得性眶骨畸形与缺损的整复

目的 探讨获得性眶骨畸形的修复重建方法.方法 采用头皮冠(半冠)状切口、下脸睫毛缘下切口以及口内龈颊沟切口入路,个别患者采用眶周原有的瘢痕做切口,对眶壁骨组织进行截骨复位,或移植下颌骨外板修复眶骨缺损,以完成眼眶完整性的重建.结果 2002年9月至2006年6月,共治疗64例获得性眶骨畸形,术后患者恢复了正常的眼眶结构和眼球位置,无严重并发症发生.结论 获得性眶骨畸形的治疗应以恢复眼眶的完整性为重要治疗目标,以截骨复位矫正眶周畸形、自体下颌骨外板为材料修复骨缺损,有较好的临床治疗效果.     

眼眶骨畸形及其外科治疗

眼眶是一个容纳眼球及其附属器的骨性腔隙。眼眶部畸形错综复杂,临床表现多样,包括眼眶部骨畸形及眼眶部软组织畸形？病因有先天性、外伤性、病理性（包括占位性）．本文仪限于眼眶骨畸形,从形态学角度可将眼眶骨（以下简称眶骨）畸形分为眼眶位置异常、容积异常及不对称畸形,分别阐述,并列举了外科矫治的方法,包括各种眶骨截骨移位、眶骨缺损修复重建等,不涉及软组织整形修复。     

一期结膜囊和眶颧重建术

目的 修复儿童期眼球摘除及放射治疗后继发眶颧凹陷,结膜囊狭窄或闭锁,以重塑中面部外形,安放义眼。方法 经颞部发际隐蔽切口,耳后带蒂皮瓣重建结膜囊,预成形羟基磷灰石块充填眶颧凹陷,颞浅血管蒂筋膜瓣覆盖置入块表面和改善外形。结果 一期再造１６例,术后２－３周安放义眼,面部对称,外形良好。结论 组织瓣和人工骨一期修复放射性眼眶结膜囊畸形,可获得良好效果。     

颅眶截骨前移结合游离皮瓣整复放疗后眶畸形

目的探讨经颅眶截骨前移结合足背游离皮瓣串联胫前筋膜瓣整复放疗后眼眶凹陷及结膜囊狭窄畸形的临床疗效。方法自2004年以来,共收治5例视网膜母细胞瘤手术及放疗后眼眶及结膜囊严重凹陷畸形,应用冠状切口经颅眶前部截骨前移,钛钉钛板坚强固定后,复原头皮瓣,再在狭窄的结膜囊中部切开向四周分离,根据结膜囊缺损的大小及颞部的凹陷范围设计足背游离皮瓣串联胫前筋膜瓣,分别移植于结膜囊及颞部凹陷部位,血管蒂与颞浅动静脉或面动脉及颈外静脉吻合。结果皮瓣全部成活,经3-6个月随访,眶外形满意,颞部凹陷明显改善。结膜囊内义眼模固定3个月后3例配戴义眼外形良好;2例较差,其中1例眼窝凹陷仍较明显,二期行义眼座置入术,另1例结膜囊挛缩,术后下穹隆过浅,二期行自体硬腭黏膜移植。上述2例经二期修整后1个月安戴义眼,外形也达到满意效果。足部供区4例愈合良好,1例延期愈合。结论经颅眶截骨前移结合游离足背皮瓣串联胫前筋膜瓣转移整复放疗后眼眶及颞区凹陷及结膜囊狭窄畸形具有可行性,一期手术即可完成。     

创伤性眼眶及眶周畸形的整复

目的：总结创伤性眼眶及眶周畸形的手术治疗经验。方法：统计分析了5年来手术治疗创伤性眼眶及眶周畸形患者16例，并随访到11例。结果：11例患者均对外观改善满意，1例功能改善欠佳。结论：外观与功能并重，使用头部冠状切口以外的其了联合切口，截骨复位内固定或附以植骨，使眶内容物复位，并采取有效的方法同时修复其他畸形，是取得满意疗效的关键。     

眼眶和结膜囊的一期再造术

从1983年起,应用颅面外科和显微外科技术一期再造眼眶和结膜囊6例。应用髂骨或肋骨移植修复眶骨和颊骨缺损;用游离前臂皮瓣移植或游离背阔肌移植充填眼内,再造结膜囊。经3个月～22个月随访,效果良好。讨论了手术的优点及经过放射治疗病例的手术特殊性等。     

眶周软组织扩张术对眶距增宽矫正后骨愈合的影响

目的建立兔眶距增宽矫正手术的动物模型,探讨使用眶周软组织扩张技术对眶内移后骨愈合的影响.方法 4～6个月龄新西兰兔16只,随机分为两组,一组为实验组,眶周软组织扩张后,行颅内外联合径路眶周截骨眶内移;另一组为对照组,眶周软组织不扩张,直接眶周截骨眶内移.16只兔均在眶内移术后12周处死,取下眶间骨胳进行内眶距测量,X线摄片和组织学检查.结果术后12周,实验组平均内眶距为(5.7±0.4)mm,对照组平均内眶距为(6.8±0.7)mm,两组有显著性差异(P<0.01).X线结果可见,术后12周实验组较对照组骨密度增高,截骨间隙缩小.组织学检查证实,对照组眶间新生骨组织较多.结论使用眶周软组织扩张技术,可有效地防止眶内移后眶距增宽的复发,证明眶周软组织不足,是眶距增宽矫正术后复发的原因之一.     

眶周软组织扩张术对眶距增宽矫正后骨愈合的影响

目的　建立兔眶距增宽矫正手术的动物模型 ,探讨使用眶周软组织扩张技术对眶内移后骨愈合的影响。方法　 4～ 6个月龄新西兰兔 1 6只 ,随机分为两组 ,一组为实验组 ,眶周软组织扩张后 ,行颅内外联合径路眶周截骨眶内移 ;另一组为对照组 ,眶周软组织不扩张 ,直接眶周截骨眶内移。 1 6只兔均在眶内移术后 1 2周处死 ,取下眶间骨胳进行内眶距测量 ,X线摄片和组织学检查。结果　术后 1 2周 ,实验组平均内眶距为 (5 .7± 0 .4 )mm ,对照组平均内眶距为 (6 .8± 0 .7)mm ,两组有显著性差异 (P <0 .0 1 )。X线结果可见 ,术后 1 2周实验组较对照组骨密度增高 ,截骨间隙缩小。组织学检查证实 ,对照组眶间新生骨组织较多。结论　使用眶周软组织扩张技术 ,可有效地防止眶内移后眶距增宽的复发 ,证明眶周软组织不足 ,是眶距增宽矫正术后复发的原因之一     

Reconstruction of the anophthalmic orbit by orbital osteotomy and free flap transfer.

It is challenging to perform an adequate reconstruction of the post enucleation irradiated orbit of patients with rentinoblastoma. Rebuilding of the orbital structure, reconstruction of the eye socket and restoration of periorbital volume are required. We reviewed 12 patients with hypoplastic orbital deformities, who have undergone orbital osteotomy and free flap transfer. Reconstruction of the orbital cavity was achieved using 'C' osteotomy of the lateral portion of the orbit in mild and moderate cases or transverse 'U' osteotomy of lateral wall, roof, and floor by intra-cranial approach in severe cases. Socket reconstruction and periorbital volume restoration was achieved using dorsalis pedis free flap transfer. From our experience the combination of orbital osteotomy and free flap transfer could meet the multi-requirements for the anophthalmic orbital reconstruction, including both orbital bony enlargement and soft tissue restoration.     

Sculpturing a fibular flap: combined horizontal/vertical osteotomy and ostectomy for reconstruction of complex craniofacial defects with one flap

A fibular flap has great versatility in reconstructive procedures. Osteomies and ostectomies enable the flap to be used for variable defects. We used combined horizontal/vertical osteotomy and ostectomy for reconstruction of complex craniofacial defects with one flap in two patients. Vertical osteotomy transforms the tubular structure of a fibula into a flat bone that can be used for reconstruction of wider defects with less vertical height. Neither vertical osteotomy nor ostectomy had negative effects on viability and bony healing of the segments in our patients. We think that the fibular flap, thanks to its versatility, can be used for reconstruction of complex orbito-zygomatic and orbito-cranial defects successfully.     

Superolateral orbital exposure and reconstruction

Based upon experience with 10 cases of surgical excision of orbital tumors, we describe a modification of the supraorbital and lateral approaches to the orbit. This technique gives a wide superior and lateral exposure of the orbital contents for microsurgical removal of orbital tumors. It is particularly applicable to large orbital neoplasms, tumors in the orbital apex, growths with intra-cranial extension, and medial orbital tumors. Two separate bone flaps are removed: (a) a craniotomy (or cranio-orbital) flap that includes the superior and lateral orbital rim and (b) a smaller, more posterior flap that includes the remainder of the roof and lateral wall of the orbit. After excision of a tumor, the orbital walls can be reconstructed in their entirety or the surgeon can leave out the smaller, posterior flap for orbital decompression. After reconstruction there are no significant anatomic, functional, or cosmetic deficits.     

Latissimus dorsi-scapula free flap for reconstruction of defects following radical maxillectomy with orbital exenteration.

A total of 21 patients with latissimus dorsi-scapula free flap reconstruction immediately following radical maxillectomy together with orbital exenteration are presented. Orbital exenteration was performed in all patients due to tumour invasion at the time of diagnosis. There was no total flap failure. Two tissue components subdivided into separate flap units with individual vascular pedicles linked by a single vascular source provide an ideal reconstructive solution for massive defects of the mid-face and orbit. Separate arcs of rotation of each flap unit permit greater mobility necessary for complex three-dimensional reconstruction. A vertically positioned angle of the scapula enables simultaneous reconstruction of the malar eminence and alveolar ridge whereas spontaneous intraoral epithelialisation of the latissimus dorsi muscle requires no additional procedure. For these reasons, in our opinion, combined latissimus dorsi-scapula free flap should be considered the first choice in reconstruction of defects following total maxillectomy with orbital exenteration.     

Aesthetic and functional management of eyelid and orbital reconstruction

Major head and neck resections may result in ocular defects that are functionally and/or aesthetically incapacitating. Restoration of the eyelid and orbit must address lateral canthal laxity, midface ptosis, eyelid retraction and ptosis, globe malposition, and dysfunctional lacrimal drainage. Here we discuss lateral canthal reconstruction, midface-lifting, eyelid spacer grafts, gold weight placement, surgical approaches to the orbit, free flap options for orbital reconstruction, and endoscopic lacrimal surgery. Successful outcomes in eyelid and orbital reconstruction depend upon proper knowledge, planning, and multidisciplinary management.     

额肌瓣在眼部整形中的应用

目的：探讨额肌瓣在眼部整形中不同部位的应用及其修复效果。方法：设计额肌瓣用于矫正眶上壁及上睑塌陷16例，眼眶内容剜除充填14例，外伤性鞍鼻18例。结果：应用额肌瓣整形48例全部成功。结论：带血管蒂额肌瓣可用于眼部整形修复，且效果良好。     

Use of the free latissimus dorsi flap in the reconstruction of extensive orbital exenterations]

The authors present the use of a free latissimus dorsi myocutaneous flap for closure of large orbital exenterations. Five cases illustrate different tumor involvements and coverage possibilities. Several technical details are studied. The vascular anastomoses are performed on cervical vessels: external carotid artery internal jugular vein. The latissimus dorsi myocutaneous flap is particularly suited for reconstruction of large facial soft tissue defects around the orbit when obliteration of the orbital cavity and restoration of deficient facial skin are necessary with correct morphological results.     

Orbital reconstruction after exenteration: use of a transorbital temporal muscle flap

Orbital exenteration is a disfiguring operation that involves the total removal of the orbital contents with partial or total excision of the eyelids. Common methods of orbit reconstruction include pectoralis musculocutaneous pedicled flap and free tissue transfer. The purpose of this study is to illustrate that the entire temporalis muscle may be used by creating a large window in the lateral orbit, without resection of the lateral orbital rim. Orbital exenteration was performed on four cadavers. A window was created in the lateral orbit using a 4-mm pineapple burr. Three parameters were measured: (1) the distance between the zygomatic arch to the superior aspect of the temporalis muscle; (2) the width of the temporalis muscle; and (3) the length and width of the lateral orbit window. The free edge of the transposed temporal muscle was then sutured to the skin edge around the bony orbit. This procedure was then performed on a 73-year-old man who had undergone right orbital exenteration for ocular melanoma and then postoperative radiation. The dimensions of the bony windows in the cadavers were as follows: mean 3.3 cm (SD +/- 0.19 cm) x 1.9 cm (SD +/- 0.18 cm), n = 4. The dimensions of the temporalis muscle in the cadavers were the following: mean 8.45 cm (SD +/- 0.60 cm) x 10.5 cm (SD +/- 0.33 cm), n = 4. In the patient, the size of the bony window was 3.7 cm x 2.1 cm (n = 1), and the dimensions of the temporalis muscle were 8.1 cm x 10.2 cm (n = 1). The patient recovered well without complication, with a well-healed skin graft over the top of the muscle flap. An adequate bony window can be made to allow transfer of the entire temporalis muscle for orbital reconstruction without resecting the lateral orbital rim or entering the middle cranial fossa. This option is a good alternative to the other commonly performed methods of orbital reconstruction because of its completion in one operative stage, short operative time, and minimal donor site morbidity.     

Reverse temporalis muscle flap for the reconstruction of orbital exenteration defects

Orbital exenteration is a surgical procedure that results in devastating functional and aesthetic losses. Many reconstructive techniques, ranging from spontaneous epithelialization to free flaps, have been described for orbital exenteration defects. The temporalis muscle flap is one of the most frequently used flaps to obliterate the orbital cavity, but only a small portion of the muscle can be used for this purpose because most of the muscle is used as the pedicle. The reverse temporalis muscle flap based on the superficial temporal vessels is a versatile flap by which the entire temporalis muscle can be elevated and carried to defects beyond the midline. The authors have used this flap for orbital reconstruction after exenteration in 6 patients with successful results. This flap enables placement of highly vascularized tissue that provides the reconstructive goals of primary healing, obliterates dead space with separation of the orbit from the nasal cavity or sinuses, provides the potential for early postoperative radiotherapy, and offers possible flaps that can be used in combination for complex, wide defects.     

Repair of orbital exenteration cavities

Several plastic surgical procedures can attenuate the unsightly effects of a disinhabited empty orbit. Only the imperatives of follow-up or very poor general status can still justify spontaneous epithelialisation, which we prefer to split skin graft. In other cases, apart from the exceptional indications of preservation of the eyelids and conjunctival sac, closure by flap is the technique of choice: temporo-frontal flap in cases of simple exenteration and temporo-jugal for the superficial plane and medio-frontal for the deep plane in radical exenterations. In young adults, when the resection is limited to the orbit, after flap closure, conjunctival reconstruction by means of a mucosal graft can be attempted without preliminary temporalis muscle transposition, as the orbital cavity is filled spontaneously and sufficiently by fibrous tissue.